CONFLICT OF INTEREST RECORD FORM

Conflict of Interest Declaration

Employees, volunteers, and staff that have a real or potential conflict of interest have a responsibility to bring this to the notice of key management personnel You must notify management personnel about conflicts of interest by filling out the form below.

Draw signature|Type signatureClear

Management Decisions (MANAGEMENT USE ONLY)

If management has decided that there is a conflict of interest and it is of material benefit to the individual, the individual must not have a decision-making role relating to the conflict issue

Draw signature|Type signatureClear